Addictive Disease Addictive Disease Concepts (HSV255)Concepts (HSV255)

Fall Semester, 2006Fall Semester, 2006

Jim Wilwerding, M.Div., MA, Jim Wilwerding, M.Div., MA, LMHC, CADC, NCCLMHC, CADC, NCC

Substance Use Substance Use

• Is there a problem?

Substance Use Substance Use

• Is there a problem?

• Is there a solution?

Substance Use Substance Use

• Is there a problem?

• Is there a solution?

• What is the solution?

Substance Use Substance Use

• Is there a problem?

• Is there a solution?

• What is the solution?

• Why should society care?

Substance Use Substance Use

• Is there a problem?

• Is there a solution?

• What is the solution?

• Why should society care?

• Who provides/pays for treatment?

Substance Use Substance Use

• Is there a problem?

• Is there a solution?

• What is the solution?

• Why should society care?

• Who provides/pays for treatment?

Addictive SubstancesAddictive Substances

• The two most damaging addictive substances in terms of death, suffering and dollar cost are legal

TobaccoTobacco

• $53-73 billion in direct medical costs per year

• $47-82 billion in lost productivity per year (Anczak & Nogler, 2003; Patkar, Vergare, Batka, Weinstein, & Leone, 2003)

• Globally, 3 million people die each year, 435,00 in the U.S. (approximately 1:5 deaths) (Mokdad, et al., 2004; Patkar, et al., 2003; Miller, 1999)

AlcoholAlcohol• In the U.S., $26 billion per year in direct medical

costs (Petrakis, Gonzalez, Rosenheck, & Krystal, 2002; Smothers, Yahr, & Ruhl, 2004)

• $67.7-138 billion per year in lost productivity (Craig, 2004; Brink, 2004)

• 20-50% of all hospital admissions are related to alcohol abuse/addiction (Greenfield & Hennessy, 2004; McKay, Koranda, & Axen, 2004)

• 85,000-140,000 people die due to alcohol use/abuse each year (Mokdad, et al., 2004)

The Scope of the ProblemThe Scope of the Problem

• The most common cause of psychosis in young adults is alcohol/drug abuse (Cohen, 1995)

• Recreational drug abuse is thought to increase the individual’s risk of ischemic stroke by 1,100% (Martin, Enevoldson, & Humphrey, 1997)

• 10-30% of adults in the U.S. have a substance use disorder (Wilens, 2004)

American Way of Life?American Way of Life?

• The economic impact of illicit chemical use/abuse is estimated between $110 billion (Connors, Donovan, & DiClemente, 2001) and $276 billion (Stein, Orlando, & Sturm, 2000) per year in the U.S.

• The annual expenditure for illicit chemicals in the U.S. was greater than the combined income of the 80 poorest Third World countries (Corwin, 1994)

Use, Abuse and AddictionUse, Abuse and Addiction

• Use sometimes referred to as “social use” is defined by traditional social standards. What is acceptable or unacceptable in society.

• Substance Abuse is defined as using a substance other than for its intended or socially acceptable standard use.

Abuse, Dependence and AddictionAbuse, Dependence and Addiction

• Substance Abuse– Maladaptive substance use with clinically significant impairment

as manifested by at least one of the following within any 1-year period:

• Failure to fulfill major role obligations at work, school, or home

• Recurrent use when physically hazardous• Recurrent legal problems• Continued use despite recurrent social or interpersonal

problems– Patient has never met criteria for Dependence

Substance DependenceSubstance Dependence

• Psychological Dependence—desire or craving to achieve the effects produced by the drug

• Physical Dependence—Bodily processes have been modified by repeated use of a drug that continued us is required to prevent withdrawal symptoms

Substance Dependence (DSM-IV)Substance Dependence (DSM-IV)

• Substance Dependence– Maladaptive substance use with clinically

significant impairment as manifested by at least three of the following within any 1-year period:

• Tolerance• Withdrawal• Taken in greater amounts or over longer time

course than intended

DSM-IV ContinuedDSM-IV Continued

• Substance Dependence• Desire or unsuccessful attempts to cut down or

control use• Great deal of time spent obtaining, using or

recovering from drug• Social, occupational, or recreational activities give

up or reduced• Continued use despite knowledge of physical or

psychological problem that is likely to have been caused or exacerbated by the substance

Addiction, Withdrawal, ToleranceAddiction, Withdrawal, Tolerance

• Addiction—broad term describing a compulsion to use a specific drug or engage in a certain activity

• Withdrawal—Discomfort and distress, including physical pain and intense cravings, experienced after stopping the use of addictive drugs

• Tolerance—decreased sensitivity to a drug brought on by its continuous use

CharacteristicsCharacteristics

• Craving/compulsion

• Loss of Control—Inconsistent control

• Consequences

Why People Use SubstancesWhy People Use Substances

• Reward/Punishment systems– Operant Conditioning– Social Learning– Expectations– Cultural Norms/Taboos

Medical Model of AddictionMedical Model of Addiction

• Jellinek (1952,1960) Proposed that alcoholism is a disease that was chronic, progressive and fatal.

• According to Jellinek, alcoholism progressed through four stages.

Jellinek’s Four StagesJellinek’s Four Stages

• Prealcoholic Phase—alcohol is used for recreational purposes and to relieve social tension

• Prodromal Phase—some severe symptoms, blackouts, etc.

• Crucial Phase—Loss of control, withdrawal, etc.

• Chronic Phase—Loss of tolerance, obsessive drinking, tremors, etc.

The “Jellinek Cycle”The “Jellinek Cycle”

• Appendix 3

• Shows the progression from use through abuse and addiction and recovery.

Additional ModelsAdditional Models (Doweiko, 2006, p.30) (Doweiko, 2006, p.30)

• Moral Model—The individual chooses to use alcohol in a problematic manner

• Temperance Model—Alcohol use in moderation

• Spiritual Model—Drunkenness is a sign that the individual has slipped from his/her intended path in life.

Additional ModelsAdditional Models (Doweiko, 2006, p.30) (Doweiko, 2006, p.30)

• Dispositional Disease Model—The alcoholic is somehow different from the nonalcoholic such as in an allergy

• Educational Model—Problems are caused by a lack of adequate knowledge about harmful effects of the chemical

• Characterological Model—Problems are based on abnormalities in the personality structure of the individual

Additional ModelsAdditional Models (Doweiko, 2006, p.30) (Doweiko, 2006, p.30)

• General Symptoms Model—People’s behavior must be viewed within the context of the social system in which they live

• Medical Model—The individual’s substance use is based on biological predispositions, such as his or her genetic heritage, brain physiology, etc.

A Disease of the SpiritA Disease of the Spirit

• Mind-Body-Spirit connection

• Priorities become misaligned

• Manipulation—recreating my reality

• Self-absorption

• Denial, Rationalization, Projection and Minimization

• Honesty as an essential component to recovery

PharmacologyPharmacology

• Drug Effects/Side-effects

• Forms of administration– Enteral (Orally, sublingually, rectally)– Parenteral (injections—subcutaneous,

intramuscular, intravenous)– Transdermal– Intranasal– Inhalation (smoking, inhaling)

PharmacologyPharmacology

• Bioavailability—concentration of the unchanged chemical at the site of action

• Absorption/Distribution/Biotransformation/Elimination

• Drug Half-Life (t1/2 )

PharmacologyPharmacology

• Dosage– Effective Dose (ED50)

– Lethal Dose (LD50)

– Therapeutic Index—ratio between ED50 and LD50

– Peak Effects

PharmacologyPharmacology

• Site of Action

• Central Nervous System– Neurotransmitters, Neurons, etc.– Receptor Sites

• Blood-Brain Barrier (BBB)